Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

Sunday, February 09, 2014

A Day In The Life Of A (Reluctant But Coerced) EHR-Using Physician - And Her Patients

A reader, a physician who wishes to be unnamed due to fear of retaliation, writes the following:

Dear Dr. Silverstein,

As you write, there is not a transaction of medical care that does not go through EHR systems.

However, these poorly usable EHR systems stifle creative and
artistic thought required to link risk, benefit, and probability of
diagnosis with risks and benefits of testing and therapeutics.

Assuring safety and efficacy with pre- and aftermarket surveillance
will maximize the possibility of achieving the potential of the
technologies.

Additionally, when I use these electronic ordering systems and
libraries of medical information, they fail to keep up with the
agility and nimbleness of my mind as I seek 'random access' to pieces of
data to formulate and synthesize diagnoses and therapeutic strategies.

The EHRs are too slow, do not have a robust (if any) search function,
randomly and whimsically store key information with ever changing
formats, and generally obfuscate what should be simple. They are
cumbersome and disable the ability to simultaneously and
contemporaneously compare myriad data points.

They get an "F" as
enablers of complex diagnostics.

Paper, since it can be organized as needed and set out on a desk to be
seen and compared as quickly as the eye registers the data, gets an "A".

The EHRs are impediments and disrupters of communication.

Example:
Just today, I was witness to the fact that a stat EKG was ordered by CPOE on a heart patient yesterday at or shortly after 4:30 pm. The
intended recipient of the order (heart station) never got it because
they close near 4:30 pm and there was no warning to the ordering health
professional that was so.

Thus, the EKG was never done, and this
morning, when the requisition was seen, no one did it because it was
ordered stat "yesterday", and the techs asked themselves "what good
would it do for a 'stat' to be done now, a day late?"

I do not know what
happened to the patient. I have many other examples of such delays
facilitated by the CPOE and EHR systems that I am required to use at numerous
facilities.

They facilitate 'stealth' alterations in care. Also just today, a
disease-critical test ordered 3 days ago was not done because it was
cancelled in 'stealth' (automatically "expired") without warning to me
by the lab responsible for doing it.

There is the "silent silo" syndrome as you've called it. Also just
today, a disease critical test ordered 5 days ago came back with
results, but the results were posted in the information 'silo' of 5
days ago. The lab screen default on the EHR only goes back 4 days (so
unless I knew to look for it, it would not be seen or acted on), further
obfuscating data and delaying treatment.

The EHRs lose data and orders. Also just today, I found that blood
coagulation monitoring tests that were ordered to be done with kidney
dialysis (3 days per week) on a patient somehow got "lost" and were not
being done for 5 days, putting my patient at risk of bleeds - or stroke
if the blood was not 'thin' enough.

I just walked in to examine a hospitalized patient with multi-organ
failure and diabetes, on multiple meds including insulin, and recovering
from respiratory failure.

The nurse anxiously informed me that the blood sugar was dangerously low. I ordered treatment stat.

I see patients in the morning before labs come back, and depend on nurses to review labs and notify me.

Turns out that the patient was hypoglycemic on yesterday morning labs
that arrived in the EHR 'silo' after I left the hospital; and was also
low in potassium, but the tests just laid there comfortable in their
silos; and were not communicated to anyone like in the old days when a
human ward clerk or other undistracted human received them and
disseminated them to the appropriate professionals.

Thus, instead of getting less insulin, the patient got the usual dose with near catastrophic adversity.

Misidentifications are facilitated by EHRs. I noticed that on
several critical clinically significant changes that arose on my
patient that were entered as such in an EHR silo by the RN, it was
stated that they called attending physician 'Dr X', which was not
me...obviously a case of EHR-facilitated misidentification.

Here is a misidentification variant: yesterday, someone (non doctor but not
clear who) ordered a specialist consultation on one of my patients under
my name. I did not order it nor was it needed, yet it showed up as an
order for me to sign.

Like you, I agree this is representative of a toxic impact of these systems on
medical care and I feel like the care environment is foul, like a
cesspool, compared to what has been replaced.

These systems of medical devices cannot be trusted in the care of
sick patients. Perhaps, they are OK for managing hang nails.

I offer no additional comments other then if I am sick, I do not want my care interfered with in this manner by IT.

5 comments:

"EHR systems stifle creative and artistic thought". Why? Because free and critical thinking skills on the part of the clinician have been deemed irrelevant by central authority.

Thoreau warned us about the use of "coercion to enforce questionable dictates". We have entered a period of medical totalitarianism. Powerless and fearful, physicians have abandoned their Hippocratic Oath.

"However, these poorly usable EHR systems stifle creative and artistic thought required to link risk, benefit, and probability of diagnosis with risks and benefits of testing and therapeutics."

This "creative and artistic thought required..." is why physicians have so many years of intense education and training. And now we squash it with EHR developed by HIT vendors who only care about the money.

We have entered the phase where EHR deaths are simply the “cost of doing business” and until we see large settlements and people personally held responsible we will continue to see bad systems with bad outcomes.

Thoreau warned us about the use of "coercion to enforce questionable dictates". We have entered a period of medical totalitarianism. Powerless and fearful, physicians have abandoned their Hippocratic Oath.

Our Tenth Anniversary

The tenth anniversary of Health Care Renewal was December 10, 2014. During our anniversary year, please help Health Care Renewal continue to challenge concentration and abuse of power in health care. Donate to FIRM, the Foundation for Integrity and Responsibility in Medicine, a US 501(c)3 non-profit. All contributions are US tax deductible as provided by US law. Our address is 16 Cutler St, Suite 104, Warren, RI, 02885. Email info at firmfound dot org for questions or comments.

FIRM welcomes support from individuals and non-profit organizations. If you are interested in donating to FIRM, please email info at firmfound dot org, snail mail us at 16 Cutler St, Suite 104, Warren, RI, 02885, USA, or see our web-site

Note that FIRM is a 501(c)3 that researches problems with leadership and governance in health care that threaten core values, and disseminates our findings to physicians, health care researchers and policy-makers, and the public at large. FIRM advocates representative, transparent, accountable and ethical health care governance, and hopes to empower health care professionals and patients to promote better health care leadership.

Health Wonk Review

Policies: Blog Roll and Comments

Our blogroll is meant to include blogs that provide interesting content relevant to what we write. It is not an endorsement in any way of any specific blog.

We accept comments, especially from registered Blogger users. If you do not wish to register with Blogger, we will accept anonymous comments, although prefer that they contain identification of the commenter.

We encourage thoughtful comments relevant to the issues brought up by the posts on Health Care Renewal.

All comments are moderated. We will reject spam, profanity, advertising of products or services not directly related to the content of this blog.

We will reject any unsubstantiated accusations or allegations.

Nonetheless, all comments represent only the opinions of those making them. The appearance of comments does not imply endorsement by the Health Care Renewal bloggers.

Please email general comments about the blog, other concerns, or questions to info AT firmfound DOT org